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医保基金结余高达2万亿,为何还要严控药费?

汤诗语 汤诗语 来源:医药魔方
2019-03-10
医保
原文

2019年2月28日,国家医疗保障局发布了《2018年医疗保障事业发展统计快报》。快报中显示,医保基金累计结存已达23234亿元;而去年人力资源和社会保障部发布的《2017年度人力资源和社会保障事业发展统计公报》中显示医保基金累计结存19386万元。据此计算,2018年医保基金结存较2017年增长了3848亿元,增幅高达19.8%。



医保基金结余已突破2万亿元,这不是一个小数目。但在2018年,医保局出台了多项控费措施,对行业震动最大的莫过于2018年12月6日揭晓的4+7城市药品集中采购结果。于是,很多人就有疑问:为何在医保基金结余规模如此庞大之时,医保局仍然想方设法控制开支?


原因一:医保支出增速快

 

2018年医保支出为17608亿元,2017年则为14422亿元。据此计算,2018年医保支出增长了3186亿元,增长率为22.1%。虽然在绝对金额上,医保支出的增长不及医保结余,但增长率上前者超过了后者。

 

如果对比历年的医保基金结余和支出数据可以发现,医保的管理机构将医保结余的可用年数(医保结余/当年医保支出)控制在1.3以上。



对比医保收入和支出的增速也可以发现,医保的管理机构尽量让支出增速不高于收入增速:



虽然我们并不知道医保管理机构以具体哪个指标为准去维持医保的收支平衡且有结余,但这些数据清晰地显示出医保整体上“以收定支、确保结余、能抗风险不穿底”的管理原则。

 

原因二:财政补贴压力大


目前国内医保分为两类,一类是职工医保,另一类是居民医保。

 

职工医保由职工的就业单位及职工本人共同缴纳,各地费率略有不同,但就业单位及职工合计缴纳的比例大多居于员工税前月薪的10%~12%之间。这一比例很高,因此职工医保的支出基本可由保费收入及职工医保结余产生的利息来覆盖,对财政补贴的依赖较少。根据财政部《关于2017年全国社会保险基金决算的说明》,2017年职工医保的收入为12134.65亿元,其中基本医疗保险费收入11224.43亿元,财政补贴收入103.53亿元;支出9298.36亿元。但职工医保的覆盖面较窄,2018年的参保人数仅为3.17亿人。

 

注:财政部历年来《全国社会保险基金决算的说明》中,2009年至2013年的财政补贴数据并未公布,因此图中显示为零


居民医保包括城乡居民医保和新农合。2018年的参保人数为10.27亿人,覆盖大多数国民。不过,根据财政部《关于2017年全国社会保险基金决算的说明》,2017年居民医保的支出为6121.16亿元,远远低于职工医保。另外,居民医保的收入极大地依赖财政补贴。2017年居民医保收入6838.33亿元,其中缴费收入1812.72亿元,财政补贴收入4918.68亿元,也即收入中的71.9%来自财政补贴。




注:2014年以前的《全国社会保险基金决算的说明》中并未说明居民医保收入中具体的财政补贴收入数字,但考虑到后续年份的其他收入较低,因此计算时假设除个人缴费收入外的收入均为财政补贴。


由于财政补贴金额并不总是公布,为估算整个基本医疗保险(即职工医保加居民医保)中的财政补贴金额,简单假设医保结余的年利息收益率为4%,且假设总收入减去职工医保的保费收入、居民医保的缴费收入及医保结余的利息收入后,剩下的部分皆为财政补贴,则计算结果如下图所示:



注:根据历年来财政部《全国社会保险基金决算的说明》的数据计算,原始数据与医保局《医疗保障事业发展统计快报》略有差异。


原因三:为医改留出空间

 

2019年2月24日央视《焦点访谈》栏目播出了一期节目《辅助用药:从滥用到规矩用》,其内容主要是讲诉“辅助用药的乱用甚至是滥用,加重了患者负担,也增加了医保开支”、“成为过度用药和利益输送的重灾区”,以安徽省卫计委控制辅助用药的使用作为正面案例,且引述了官员的话“挤掉了这一部分的费用”、“这种费用腾出来的空间,用于调整医疗服务价格,用于薪酬制度的改革”,并在节目最后提到“一份全国性的辅助用药目录呼之欲出”。



对医务人员劳动服务的定价过低,甚至沿用十多年前的医疗服务价格,以至于医务人员必须通过药品才能获得合理的报酬,即所谓“以药养医”,这是国内医疗体系的痼疾。这不仅制造了大量的“灰色地带”,也带来了高昂却不必要的摩擦成本。

 

从这期《焦点访谈》中卫健委官员的思路看,未来医改的方向可能是提高医疗服务的价格、提升医务人员的薪酬,从而让医务人员的合理报酬可以直接通过薪酬来实现,同时,消除高昂的摩擦成本后,用药将更加合理,药价也将更加低廉。

 

实际上,2018年卫健委和医保局对辅助用药的控费收效显著。根据某上市公司公告中引述的IQVIA数据,截至2018年11月份,大医院医药市场同比增长了3.3%,但辅助用药下降了7.4%,而治疗性用药增长了11.0%,对照非常显著。

在对辅助用药的控费取得了显著成效后,2018年12月份,医保局通过“4+7集采”,大幅降低了部分治疗性用药的价格,消除了这些品种高昂的摩擦成本。如果未来“集采”模式被推广,那么这将为医疗服务价格改革留下了巨大的操作空间,“以药养医”的时代或将终结。

 

原因四:人口结构变化带来的压力

 

上述三点皆为医保控费的短期因素,人口结构的变化则是长期变量。我们的邻国日本的统计数据完善,可供借鉴参考。


根据日本厚生劳动省每年发布的《国民医疗费》报告中的数据可以计算出65岁及以上人士与65岁以下人士的人均医疗费的对比,大体上前者是后者的4倍左右。


而根据2016年的《国民医疗费》报告,各年龄层次的人均医疗费分布如下图所示:


那么,假设国内各年龄层次的人均医疗费分布状态与日本相同,那么未来对医保会有多大的压力?

 

对长期人口结构的预测涉及到诸多变量,相对复杂,在这里采用联合国对中国人口预测的中值数据。不过在这里必须指出,部分学者,如易富贤博士,对联合国的预测有不同意见,认为联合国的预测过于乐观。下面的这组图中,第一张图是2010年人口普查的实际数据,后续的图均为预测。



以2010年为基数,假设除人口数和年龄结构外的其他参数均不变化(药价不上涨、用药结构不变化等等),计算未来国民医疗费相对2010年的倍数,如下图所示:



同时,还必须考虑到,未来15至65岁的劳动人口的数量和占比均会下降。这对职工医保的影响巨大,因为这会令缴纳保费者减少,而使用医保者增加。



因此,从长期看,为了保证在对国民的“全覆盖”下,医保仍能为较高质量的医疗服务和药品提供支付保障,控费将始终处于进行时。

 

而对于医药行业来说,医保局对药品的合理使用、合理价格的持续关注将会导致药品市场发生翻天覆地的变化,未来中国医药市场的状态也将日益趋同于海外成熟市场。

 

参考资料:

1. 财政部:全国社会保险基金决算的说明

2. 医保局:医疗保障事业发展统计快报

3. 人社部:人力资源和社会保障事业发展统计公报

4. 厚生劳动省:国民医疗费的概况

5. 中央电视台焦点访谈:辅助用药:从滥用到规矩用

6. 联合国:World Population Prospects


机器翻译

On February 28, 2019, the National Health Insurance Bureau issued the "2016 Medical Insurance Development Statistics Express". The Express News showed that the accumulated balance of the medical insurance fund has reached 2,323.4 billion yuan. Last year, the Ministry of Human Resources and Social Security released According to the "Statistical Bulletin on the Development of Human Resources and Social Security in 2017", the accumulated balance of medical insurance funds was 193.86 million yuan. According to this calculation, the balance of medical insurance funds in 2018 increased by 384.8 billion yuan compared with 2017, an increase of 19.8%.

The medical insurance fund balance has exceeded 2 trillion yuan, which is not a small amount. But in 2018, the medical insurance bureau issued a number of control measures, the biggest shock to the industry is the announcement on December 6, 2018. 4+7 results of centralized drug procurement in cities. As a result, many people have questions: Why is the Health Insurance Bureau still trying to control expenses when the balance of the medical insurance fund is so large?

Cause 1: The growth rate of medical insurance expenditure is fast

The medical insurance expenditure in 2018 is 1,760.8 billion yuan, and in 2017, it is 144.2 billion yuan. According to this calculation, the medical insurance expenditure in 2018 has increased by 3186. 100 million yuan, the growth rate is 22.1%. Although the increase in medical insurance expenditure is less than the medical insurance balance in absolute terms, the growth rate is higher than the latter.

If you compare the medical insurance fund balances and expenditure data over the years It can be found that the medical insurance management agency controls the number of years of medical insurance savings (medical insurance balance / current medical insurance expenditure) to be above 1.3.

Comparing the growth rate of medical insurance income and expenditure can also be found, the medical insurance management agency Let the growth rate of expenditure not be higher than the growth rate of income:

Although we do not know which specific indicator of the medical insurance management agency is responsible for maintaining the balance of medical insurance and having a balance, these data clearly show On the whole, the medical insurance system is based on the management principle of “receiving the balance. Ensuring the balance. It can resist the risk without bottoming out”.

Cause 2: The pressure on financial subsidies is large

The current domestic medical insurance is divided into two. Class, one is employee medical insurance, and the other is resident medical insurance.

Employee medical insurance The employment unit and the employee themselves pay together, and the local rates are slightly different, but the proportion of the total paid employment units and employees is mostly between 10% and 12% of the employee's monthly salary. This ratio is very high, so the employee's medical insurance Expenditure can basically be covered by premium income and interest generated by employee medical insurance balance, and less dependent on financial subsidies. According to the Ministry of Finance's "Note on the 2017 National Social Insurance Fund Final Account", the income of employee medical insurance in 2017 was 1,213,465 million yuan. Among them, the basic medical insurance premium income was 112.243 billion yuan, and the financial subsidy income was 10.353 billion yuan. The expenditure was 929.836 billion yuan. However, the coverage of employee medical insurance was narrow. The number of participants in 2018 was only 317 million.

Note : In the "Description of the National Social Insurance Fund Final Account" of the Ministry of Finance over the years, the financial subsidy data from 2009 to 2013 has not been published, so the figure shows zero.

Resident medical insurance includes medical insurance for urban and rural residents and new Nonghe. In 2008, the number of participants was 1.027 billion, covering most of the nationals. However, according to the Ministry of Finance’s “Notes on the 2017 National Social Insurance Fund Final Account”, 2017 residents The expenditure is 61.216 billion yuan, far lower than the employee medical insurance. In addition, the income of residents' medical insurance is greatly dependent on financial subsidies. In 2017, the income of residents' medical insurance is 683.833 billion yuan, of which the income from payment is 181.272 billion yuan and the income from financial subsidies is 491.868 billion yuan. That is, 71.9% of the income comes from financial subsidies.

Note: The “National Social Insurance Fund Final Account Statement” before 2014 does not specify the specific financial subsidy income figures of residents’ medical insurance income, but considering Other incomes in subsequent years are lower, so the calculation assumes that the income other than personal contribution income is financial subsidy.

Because the amount of financial subsidies is not always announced, in order to estimate the entire basic medical insurance (ie employees) The amount of financial subsidy in medical insurance plus resident medical insurance, simply assume that the annual interest rate of the medical insurance balance is 4%, and assume that the total income minus the premium income of the employee's medical insurance. After the income of the resident medical insurance and the interest income of the medical insurance balance, The next part is the financial subsidy, and the calculation results are as shown below:

Note: According to the Ministry of Finance, the National Social Insurance Fund’s final account statement The data is calculated, and the original data is slightly different from the Medical Insurance Bureau's “Development Statistics Express”.

Cause 3: Leave room for medical reform

CCTV on February 24, 2019 The "Focus Interview" column broadcasted a program "Auxiliary Drugs: From Abuse to Rules", which mainly talked about "disuse and even abuse of auxiliary drugs, which increased the burden on patients and increased medical insurance expenses." It became the hardest hit area for over-medication and benefit transmission. The use of the auxiliary medicines controlled by the Anhui Provincial Health Planning Commission was a positive case, and the official’s words were quoted as “squeezing out the cost of this part.” “The space for this kind of expenses, It is used to adjust the price of medical services for the reform of the salary system, and at the end of the program, “a national catalogue of auxiliary medicines is coming out.”

The pricing of medical services for medical staff is too low. Even the price of medical services used more than ten years ago, so that medical personnel must pass the medicines to get a reasonable reward, that is, the so-called "medication by medicine", which is a dysentery of the domestic medical system. This not only makes a big The amount of "grey zone" also brings high but unnecessary friction costs.

From the perspective of this issue of "Focus Interview", the health care committee officials may look forward to improving medical services in the future. The price of the medical staff is raised so that the reasonable remuneration of the medical staff can be achieved directly through the salary. At the same time, after eliminating the high friction cost, the medication will be more reasonable and the drug price will be cheaper.

In fact, in 2018, the Health and Health Insurance Commission and the Medical Insurance Bureau paid significant attention to the control fees for auxiliary drugs. According to the IQVIA data quoted in a public company announcement, as of November 2018, the pharmaceutical market of the big hospital increased by 3.3% year-on-year, but auxiliary The medication decreased by 7.4%, while the therapeutic medication increased by 11.0%. The control was very significant.

After the remarkable effect on the control of the adjuvant medication, in December 2018, the medical insurance bureau passed the "4+ 7 episodes of mining, significantly reducing the price of some therapeutic drugs, eliminating the high friction costs of these varieties. If the future "collection" mode is promoted, then this will leave a huge operational space for medical service price reform The era of "medication with medicine" may end.

Cause 4: Pressure brought about by demographic changes

The above three points are short-term factors for medical insurance control fees, population The structural changes are long-term variables. The statistical data of our neighboring countries in Japan is perfect and can be used for reference.

According to the data in the “National Medical Expenses” report issued by the Ministry of Health, Labor and Welfare every year, the data can be calculated. The per capita medical expenses of people aged 65 and over and those under the age of 65 are generally about 4 times that of the latter.

According to the 2016 National Medical Expenses report, all age groups The distribution of per capita medical expenses is shown in the following figure:

So, assuming that the distribution of per capita medical expenses at all age levels in the country is the same as that in Japan, how much pressure will there be for medical insurance in the future?

The prediction of the long-term population structure involves many variables and is relatively complex. The median data of the United Nations population prediction for China is used here. However, it must be pointed out here that some scholars, such as Dr. Yi Fuxian, The United Nations has different opinions and believes that the UN's forecast is too optimistic. In the following set of figures, the first picture is the actual data of the 2010 census, and the subsequent figures are predictions.

To 2010 Based on the year, it is assumed that the parameters other than the population and age structure do not change (the drug price does not rise. The structure of the drug does not change, etc.), and the future national medical expenses are calculated as multiples of 2010, as shown in the following figure: p>

At the same time, it must be taken into account that the number and proportion of the working population between the ages of 15 and 65 will decline. This has a huge impact on the medical insurance of employees, because it will reduce the number of people who pay the premiums, and the use of medical insurance. Increase.

Therefore, in the long run, in order to ensure that under the “full coverage” of the nationals, the medical insurance can still provide payment guarantee for higher quality medical services and medicines, and the control fees will always be in progress.

and for In the pharmaceutical industry, the medical insurance bureau uses the drug rationally. The continuous attention to reasonable prices will lead to earth-shaking changes in the pharmaceutical market. In the future, the status of the Chinese pharmaceutical market will increasingly converge to mature overseas markets.

References:

1. Ministry of Finance: Explanation of the National Social Insurance Fund Final Account

2. Medical Insurance Bureau: Medical Insurance Development Statistics Express

3. Ministry of Social Affairs: Statistical Bulletin on the Development of Human Resources and Social Security Services

4. Ministry of Health, Labour and Welfare: Overview of National Medical Expenses

5. CCTV Focus Interview: Auxiliary Medication: From Abuse to Rules used

6. United Nations: World Population Prospects

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